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Movement Disorder Emergencies in the Elderly: Recognizing and Treating an Often-Iatrogenic Problem

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Movement Disorder Emergencies in the Elderly: Recognizing and Treating an Often-Iatrogenic Problem REVIEW BABAK TOUSI, MD* CME Clinical Assistant Professor of Medicine, CREDIT Cleveland Clinic Lerner College of Medicine of Case Western Reserve University; Senior and Behavioral Health, Lutheran Hospital, Cleveland Movement disorder emergencies in the elderly: Recognizing and treating an often-iatrogenic problem ■ ABSTRACT LTHOUGH WE TEND to think of move- A ment disorders as chronic conditions, Movement disorder emergencies in the elderly—such as some of them can present as true emergencies rigidity, dystonia, hyperkinetic movements, and psychiatric in which failure to diagnose the condition and disturbances—are challenging to manage. Many cases treat it promptly can result in significant sick- are iatrogenic. In theory, some cases could be avoided by ness or even death. anticipating them and by avoiding polypharmacy and Many cases are iatrogenic, occurring in potentially dangerous drug interactions. patients with Parkinson disease or those tak- ing antipsychotic or antidepressant medica- ■ KEY POINTS tions when their regimen is started or altered. Elderly patients are particularly at risk, as they Supportive measures must be taken immediately take more drugs and have less physiologic to maintain the functions of vital organs. reserve. Movement disorder emergencies in elder- Serotonin syndrome, which can cause rigidity or stiffness, ly patients can be difficult to diagnose and can be prevented by avoiding multidrug regimens. treat, since many patients are taking more than one medication: polypharmacy raises the possibility of interactions, and different drugs Withdrawing or decreasing the dose of dopaminergic can cause different movement disorder syn- drugs in patients with Parkinson disease can cause dromes. Moreover, because so many patients parkinsonism-hyperpyrexia syndrome, a condition similar are at risk—for example, more than 1 million to neuroleptic malignant syndrome. people in the United States now have Parkinson disease, and the number is grow- Metoclopramide (Reglan) accounts for nearly one-third of ing—it is important for physicians who take all drug-induced movement disorders. The entire spectrum care of the elderly to be more informed about of drug-induced movement disorders, ranging from subtle these disorders, especially the presenting to life-threatening, can ensue from its use. symptoms. ■ Complications of Parkinson disease include hallucinations, SCOPE OF THIS ARTICLE dementia, depression, psychosis, and sleep disorders. Movement disorder emergencies can be classi- fied into four main categories (TABLE 1): •Disorders presenting with rigidity or stiffness •Disorders presenting with dystonia •Disorders presenting with hyperkinetic *Dr. Tousi has disclosed that he has received honoraria from UCB for teaching and speaking. movements CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 • NUMBER 6 JUNE 2008 449 Downloaded from www.ccjm.org on September 26, 2021. For personal use only. All other uses require permission. MOVEMENT DISORDER EMERGENCIES TOUSI TABLE 1 this combination is popular for the treat- ment of depression and anxiety) Movement disorder emergencies •A tricyclic agent such as imipramine in the elderly (Tofranil) Disorders presenting with rigidity or stiffness •A serotonin and norepinephrine reuptake Serotonin syndrome inhibitor such as venlafaxine (Effexor). Neuroleptic malignant syndrome In addition, antiparkinson drugs such as Parkinsonism-hyperpyrexia syndrome levodopa and selegiline (Eldepryl) enhance Akinetic syndrome after failure of a deep brain stimulator serotonin release. Disorders presenting with dystonia Signs and symptoms. Serotonin syn- Acute dystonic reaction drome is characterized by: Laryngeal dystonia accompanied by multiple system atrophy •Severe rigidity Sudden withdrawal of baclofen (Kemstro, Lioresal) • Dysautonomia •Change in mental status. Disorders presenting with hyperkinetic movements Other clinical findings include fever, gas- Acute hemichorea and hemiballism Severe parkinsonian dyskinesia trointestinal disturbances, and motor restless- Drug-induced myoclonus ness. Clonus is the most important finding in Drug-induced akathisia establishing the diagnosis.2 Some features, such as shivering, tremor, Disorders with psychiatric presentations and jaw quivering, differentiate serotonin syn- Hallucinations and psychosis in Parkinson disease drome from neuroleptic malignant syndrome (see below; TABLE 3). In addition, signs of neu- roleptic malignant syndrome evolve over sev- •Disorders presenting with psychiatric dis- eral days, whereas serotonin syndrome has a turbances. rapid onset. Hyperactive bowel sounds, Of these, the scenarios most likely to diaphoresis, and neuromuscular abnormalities require emergency evaluation in the elderly distinguish serotonin syndrome from anti- Any drug that are acute hypokinetic and hyperkinetic syn- cholinergic toxicity. enhances dromes and psychiatric presentations. This The syndrome may initially go unrecog- article discusses movement disorder emergen- nized and can be mistaken for viral illness or serotonin can cies in the elderly, focusing on the more com- anxiety.4 Manifestations range from mild to cause serotonin mon disorders with common presentations. life-threatening; initially, it may present with akathisia and tremor. The symptoms progress syndrome ■ DISORDERS PRESENTING rapidly over hours and can range from WITH RIGIDITY OR STIFFNESS myoclonus, hyperreflexia, and seizures to severe forms of rhabdomyolysis, renal failure, Serotonin syndrome and respiratory failure. The hyperreflexia and Serotonin syndrome can occur in a patient clonus seen in moderate cases may be consid- recently exposured to a serotonergic drug or, erably greater in the lower extremities than in more commonly, to two or more drugs.3 Any the upper extremities.5 drug that enhances serotonergic neurotrans- No laboratory test confirms the diagnosis, mission can cause serotonin syndrome (TABLE but tremor, clonus, or akathisia without addi- 2), especially in the elderly, who may not be tional extrapyramidal signs should lead to the able to tolerate serotonergic hyperstimulation. diagnosis if the patient was taking a serotoner- Chief among the offenders are the selec- gic medication.5 The onset of symptoms is tive serotonin-reuptake inhibitors (SSRIs), usually rapid. The majority of patients present either alone or in combination. This syn- within 6 hours after initial use of the medica- drome occurs in 14% to 16% of patients who tion, an overdose, or a change in dosing.5 overdose on SSRIs.1 Examples of combina- Treatment. The first steps are to stop the tions that can lead to serotonin syndrome are serotonergic medication and to hydrate and an SSRI plus any of the following: cool the patient to counteract the hyperpyrex- • An anxiolytic such as buspirone (BuSpar; ic state. Benzodiazepine drugs are important in 450 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 75 • NUMBER 6 JUNE 2008 Downloaded from www.ccjm.org on September 26, 2021. For personal use only. All other uses require permission. TABLE 2 Drugs and drug interactions associated with the serotonin syndrome Drugs associated with the serotonin syndrome Dexfenfluramine (Redux) Selective serotonin-reuptake inhibitors Fenfluramine (Pondimin) Sertraline (Zoloft) Antibiotics and antivirals Fluoxetine (Prozac, Sarafem) Linezolid (Zyvox), a monoamine oxidase inhibitor Fluvoxamine (Luvox) Ritonavir (Norvir), through inhibition of Paroxetine (Paxil) cytochrome P-450 enzyme isoform 3A4 Citalopram (Celexa) Imipramine (Tofranil) Other antidepressant drugs Over-the-counter cough and cold remedies Trazodone (Desyrel) Dextromethorphan Nefazodone (Serzone) Drugs of abuse Buspirone (BuSpar) Methylenedioxymethamphetamine (MDMA, Clomipramine (Anafranil) or “ecstasy”) Venlafaxine (Effexor) Lysergic acid diethylamide (LSD) Mirtazapine (Remeron) 5-methoxy diisopropyltryptamine (“foxy methoxy”) Monoamine oxidase inhibitors Syrian rue (contains harmine and harmaline, Phenelzine (Nardil) both monoamine oxidase inhibitors) Moclobemide (Manerix) Dietary supplements and herbal products Clorgiline Tryptophan Isocarboxazid (Marplan) Hypericum perforatum (St. John’s wort) Anticonvulsants Panax ginseng (ginseng) Valproic acid (Depakote) Lithium (Eskalith) Analgesics Drug interactions associated Meperidine (Demerol) with severe serotonin syndrome Fentanyl (Actiq, Duragesic, Sublimaze) Phenelzine and meperidine Tramadol (Ultram) Tranylcypromine and imipramine Pentazocine (Talwin) Computer- Phenelzine and selective serotonin-reuptake Antiemetic agents inhibitors Ondansetron (Zofran) based ordering Paroxetine and buspirone Granisetron (Kytril) Linezolid and citalopram systems can Metoclopramide (Reglan) Moclobemide and selective serotonin-reuptake Antimigraine drugs help one avoid inhibitors Sumatriptan (Imitrex) Tramadol, venlafaxine, and mirtazapine drug Bariatric medications FROM BOYER E, SHANNON S. SEROTONIN SYNDROME. N ENGL J MED interactions Sibutramine (Meridia) 2005; 352:1112–1120. controlling agitation, regardless of its severi- cases, intensive care may be required with ty.5 Propranolol (Inderal) is not recommend- immediate sedation, neuromuscular paralysis, ed, as it may cause hypotension and shock in and intubation. patients with autonomic instability.5 In most cases, patients improve rapidly. Patients with moderate cases may addi- Comment. Serotonin syndrome can be tionally benefit from cyproheptadine avoided by educating physicians and by mod- (Periactin), an antihistamine that antagonizes ifying prescribing practices.5 Avoiding mul-
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