EXTRAPYRAMIDAL EFFECTS OF ANTIPSYCHOTIC MEDICATIONS
Acute dystonic reactions
Severe muscle spasms that can be life-threatening if not treated immediately
(severe twisting of the neck to the side) or retrocollis (head pulling back)
(severe arching of the back)
severe rolling of the eyes into the head
(spasm of the throat that causes impaired breathing and swallowing and may require emergency tracheostomy)
(spasms of the face, lips, and tongue that cause difficulty with talking, chewing, and eating)
Acute dystonic reactions treatments
IM administration of anticholinergics, such as diphenhydramine and benztropine, to ease the adverse effects
Abnormal muscle movements that aren't as severe as spasms
- Facial tics and twitches
- Chewing movements
- Lip smacking
- Aimless movements of the tongue
- Shoulder shrugging
- Pedaling movements of legs
- Flailing arms
- Decreased dosage of antipsychotic
- In some patients, prophylactic treatment with antiparkinsonian drugs such as benztropine
Late onset of any of the dyskinesias; usually doesn't occur until 4 to 6 months after treatment with an antipsychotic has started; can also occur with use of antidepressants that affect dopamine receptors; signs and symptoms may continue long after discontinuation of the drug3
- Facial grimacing
- Jaw swinging
- Repetitive chewing
- Tongue protrusion
- Lip smacking, puckering, and pursing
- Rapid eye blinking
- Rapid movements of the arms, legs, and trunk3
Tardive dyskinesia treatments
- Prevention with careful monitoring and continuous assessment for adverse effects
- Use of the lowest possible dosage
Parkinsonism (or pseudoparkinsonism)
Reactions that mimic the onset of Parkinson's disease; generally, one of the earliest reactions (possibly occurring within days of starting an antipsychotic medication)
- Stiffness and slowness of voluntary movement
- Masklike immobility of facial muscles
- Stooped posture
- Slow, monotonous speech
- Shuffling gait that speeds up on its own
Parkinsonism (or pseudoparkinsonism) treatments
IM or IV administration of anticholinergics, such as diphenhydrAMINE and benztropine
Continuous muscle activity that's less intense than dystonias or dyskinesias; the most common type of extrapyramidal symptom
- Intolerance of inactivity
- Continuous agitation and restlessness
- Constant leg and fine movements
Administration of a different antipsychotic or reduced dosage of the current antipsychotic
Factors that may increase the risk of extrapyramidal symptoms in patients taking antipsychotic drugs
age, gender (female), race (black), psychiatric diagnosis, history of substance abuse, cognitive deficits, previous experience of extrapyramidal adverse effects, inconsistencies in the treatment regimen, coexisting brain damage or diabetes mellitus, or history of a mood disorder.5
The Abnormal Involuntary Movement Scale (AIMS)
a screening tool that assesses for extrapyramidal adverse effects. It provides a qualitative assessment by measuring atypical movements in seven different areas of the body and rating their intensity
12-item scale used to assess the severity of dyskinesias (especially orofacial, extremity, and truncal movements)
examination procedure for AIMS
have the patient sit in a hard, firm, armless chair and quietly observe the patient while you perform these steps:
1st step of AIMS
Ask the patient whether there's anything in the mouth (for example, gum or candy); if there is, ask the patient to remove it.
2nd step of AIMS
Ask the patient about the current condition of the teeth. Does the patient wear dentures? Do the patient's teeth or dentures bother the patient now?
3rd step of AIMS
Ask the patient whether the patient notices any unusual movements in the mouth, face, hands, or feet. If yes, ask the patient to describe them and the extent to which they currently bother the patient or interfere with activities.
4th step of AIMS
Have the patient sit in the chair with the hands on the knees, legs slightly apart, and feet flat on the floor. Look at the entire body for movements while the patient is in this position.
5th step of AIMS
Ask the patient to sit with the hands hanging unsupported. If the patient is male, his hands should be between his legs; if female and wearing a dress, her hands should hang over her knees. Observe the hands and other body areas.
6th step of AIMS
Ask the patient to open the mouth. Observe the tongue at rest within the mouth. Repeat this step.
7th step of AIMS
Ask the patient to protrude the tongue. Observe for abnormalities of tongue movement
8th step of AIMS
Ask the patient to tap the thumb with each finger as rapidly as possible for 10 to 15 seconds, first with the right hand and then with the left hand. Observe the patient's facial and leg movements.
9th step of AIMS
Flex and extend the patient's left and right arms, one at a time. Note any rigidity and rate it.
10th step of AIMS
Ask the patient to stand up. Observe the patient in profile, assessing all body areas, including the hips.
11th step of AIMS
Ask the patient to extend both arms in front with the palms down. Observe the patient's trunk, legs, and mouth.
12th step of AIMS
Have the patient walk a few paces, turn, and walk back to the chair. Observe the hands and gait. Repeat this step.
AIMS Scoring Procedure
Complete the examination procedure before making ratings. For the movement ratings (the first three categories below), rate the highest severity observed:
- 0 = none
- 1 = minimal (may be extreme normal)
- 2 = mild
- 3 = moderate
- 4 = severe.
Subtract one point if you see movements only on activation. If the patient scores 2 in two or more movements or scores 3 or 4 in a single movement, results of the AIMS examination are positive. Don't sum scores. For example, if the patient scores 1 in four movements, the patient does not have a positive AIMS score of 4.
Facial and Oral Movements
Muscles of facial expression—for example, movements of forehead, eyebrows, periorbital area, and cheeks and including frowning, blinking, and grimacing of upper face
Lips and perioral area—for example, puckering, pouting, and smacking
Jaw—for example, biting, clenching, chewing, mouth opening, and lateral movement
Tongue, rating only an increase in movement in and out of mouth, not inability to sustain movement
Upper (arms, wrists, hands, fingers), including movements that are choreic (rapid, objectively purposeless, irregular, spontaneous) or athetoid (slow, irregular, complex, serpentine), and not including tremor (repetitive, regular, rhythmic movements)
Lower (legs, knees, ankles, toes)—for example, lateral knee movement, foot tapping, heel dropping, foot squirming, and inversion and eversion of the foot
Neck, shoulders, hips—for example, rocking, twisting, squirming, and pelvic gyrations, including diaphragmatic movements
Severity of abnormal movements 0 1 2 3 4 (based on the highest single score on the above items)
9. Incapacitation due to abnormal movements
0 1 2 3 4
Patient’s awareness of abnormal movements:
- 0 = no awareness
- 1 = aware, no distress
- 2 = aware, mild distress
- 3 = aware, moderate distress
- 4 = aware, severe distress
Current problems with teeth, dentures, or both
- 0 = no
- 1 = yes
Does patient usually wear dentures?
- 0 = no
- 1 = yes