Akathisia - A state of inner restlessness, with a strong desire/compulsion to move

Clinical features

-          Foot stamping when seated

-          Crossing/uncrossing legs

-          Rocking from foot to foot

-          Pacing up and down

-          Akathisia may be mistaken for psychotic agitation and has been linked with suicidal ideation and aggression towards others

Rating scales

Barnes akathisia scale (appendix 1)

Prevalence

Approximately 25%, less with second generation antipsychotics in decreasing order; aripiprazole, lurasidone, risperidone, olanzapine, quetiapine and clozapine.

Time taken to develop

Occurs within hours to weeks of starting antipsychotics or increasing the dose.

Tardive akathisia can take longer to develop and persist after antipsychotics have been withdrawn

Treatment

Depending on the clinical circumstances;

-          Reduce antipsychotic dose

-          Change to an antipsychotic with a lower propensity for akathisia

-          Anticholinergics (e.g. procyclidine) are usually ineffective

-          Benzodiazepines can be used short term during initiation

-          The following drugs may reduce akathisia (all unlicensed for this indication- see Maudsley for dosing);

o   Propranolol

o   Clonazepam (low dose)

o   H₂ antagonists e.g. Mirtazapine, trazodone

The Maudsley- Practice guidelines for physical health conditions in psychiatry has a good flow chart showing treatment options (Athens login required)

Dystonia - Uncontrolled muscular spasm in any part of the body

Clinical features

-          Abnormal face and body movements

-          Oculogyric crisis (eyes rolling upwards)

-          Torticollis (head and neck twisting to the side)

-          Inability to swallow or speak clearly

-          In extreme cases, back may arch or jaw dislocate

Rating scales

No specific scale

Prevalence

Approximately 10% but more common;

-          In young males

-          In neuroleptic naïve

-          With high potency antipsychotics

Rare in the elderly

Time taken to develop

Can occur within hours of starting antipsychotics (minutes if given via IM or IV)

Treatment

Anticholinergic drugs given PO, IM or IV depending on the severity of the symptoms;

-          Example PO anticholinergic: procyclidine 2.5mg three times daily, increased in steps of 2.5mg-5mg daily if required, up to maximum 30mg daily in 2-4 divided doses ^[3]

-          For procyclidine IM dosing please consult the BNF. The maximum IM procyclidine dose is 20mg daily ^[4] but in acute crisis doses of up to 30mg can be used.

-          Elderly patients may be more susceptible to the anticholinergic effects of procyclidine and a reduced dosage may be required

-          Response to IM takes ~20 minutes

-          If after 3 doses of IM, symptoms have not resolved then patient should be transferred to acute care

-          Remember: patient may be unable to swallow

Reduce dose or switch to an antipsychotic with lower propensity

Tardive Dyskinesia – Abnormal movements

Clinical features

-          Lip smacking or chewing

-          Tongue protrusion ‘fly catching’

-          Pill rolling or piano playing (choreiform hand movements)

-          Pelvis thrusting

-          Severe orofacial movements can lead to difficult speaking, eating or breathing. Symptoms can worsen under stress.

Rating scales?

Abnormal Involuntary Movement Scale (AIMS) (appendix 2)

Prevalence

5% of patients per year of antipsychotic exposure.

More common in;

-          Older age

-          Affective illness

-          Those who have had acute EPS early in treatment

-          Genetic predisposition

-          Length of exposure to antipsychotics

Time taken to develop

Months to years. Approximately 50% of cases are reversible

Treatment

Depending on the clinical circumstances;

-          Stop anticholinergic if prescribed

-          Reduce dose of antipsychotic

-          Change to an antipsychotic with lower propensity for tardive dyskinesia

-          Clozapine is the antipsychotic most likely to be associated with resolution of symptoms, quetiapine may also be useful.

-          Tetrabenazine is licensed for the treatment of TD, starting at 12.5mg and titrating to 25-75mg/day.

Pseudoparkinsonism

Clinical features

-          ‘mask like’ face

-          Resting tremor

-          Rigidity

-          Cogwheeling

-          Bradykinesia

-          Bradyphenia

Rating scales

Simpson-Angus EPS Rating Scale (appendix 3)

Prevalence

Approximately 20%. More common in:

-          Elderly females

-          Those with pre-existing neurological damage

Time taken to develop

Days to weeks after initiation or dose changes

Treatment

Depending on the clinical circumstances;

-          Consider cautious dose reduction of causative agent

-          If side effects persist, consider switching to an antipsychotic with lower propensity to cause parkinsonism (aripiprazole, quetiapine, olanzapine, clozapine)

-          Prescribing an anticholinergic, monitoring for side effects (dry mouth, constipation, urinary retention, cognitive impairment). Review use regularly. Example agents: procyclidine 2.5mg three times daily, increased in steps of 2.5mg-5mg daily if required, up to maximum 30mg daily in 2-4 divided doses ^[3]

-          After 3 months should be gradually withdrawn, to prevent cholinergic rebound, and restarted if symptoms reappear ^[5]