Antiparkinsonian Drugs

1 PARKINSONS DISEASE & EXTRAPYRAMIDAL SIDE

EFFECTS

Extrapyramidal side effects: serious and dangerous complications of

treatment with psychotropic drugs
o These are the result of biochemical changes similar to Parkinsons
The four cardinal symptoms of Parkinsons:
o
o

Tremors
Bradykinesia

o
o

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
receptors

1.1 SPECIFIC 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
o Torticollis: contracted position of the neck
o Oculogyritic crisis: contracted position of the eyes upward
o 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
o Treated with muscle relaxants
Pisa syndrome: patient leaning to one side; older adults more vulnerable

1.2 PEOPLE

AT

RISK

FOR

EPSES

Women
Patients with first episode of
schizophrenia

Older adults
Patients with affective
symptoms

2 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 balance

2.1 SIDE 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, nervousness

2.2 PERIPHERAL 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 clothing

2.3 ANTICHOLINERGIC 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 retention

2.4 RISKS ASSOCIATED

WITH ANTICHOLINERGIC USE

Might be lethal in overdose
Induce psychosis
Induce dependence
Erectile dysfunction
Exacerbate tardive dyskinesia
Paralytic ileus

2.5 ANTICHOLINERGICS
REACTION

IN

OLDER PEOPLE: MORE PRONOUNCED

Slower metabolism and elimination

Deficits in cholinergic transmission
Difficulties in older men with prostate enlargement can be exacerbated
Cognitive impairment results

2.6 INTERACTIONS

WITH ANTICHOLINERGICS
Intensifies sedative effects when combined with CNS depressants
Decreased absorption with antacids and antidiarrheals

2.7 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 antacids

2.8 ANTICHOLINERGIC DRUGS

Benztropine (Cogentin): used to treat all parkinsonian-like disorders

o Most frequently prescribed anticholinergic
o 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 form

3 OTHER 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 dyskinesia

4 PREVENTION

Establish if patient is high-risk group

Obtain baseline info about EPSEs
Chose antipsychotic with lower probability of causing EPSEs
o High-risk: haldol, prolixin, other traditional

o 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