Tardive Dyskinesia

Question 1

55 year old man presents with tardive dyskinesia; he is a known schizophrenia and takes haloperidol. How would you manage this patient? Describe some movement disorders that can be caused by neuroleptic drugs.

Answer 1

Impression
Tardive dyskinesia is a form of EPSE which are known adverse effects of anti-psychotic medication, particularly first generation antipsychotics such as haloperidol.

Priorities:

• conduct full assessment for any other immediate concerns and adverse effects
• cease current anti-psychotic medication

Question 2

Other movement disorders caused by neuroleptics

Answer 2

Other movement disorders:
Anti-psychotic medications are associated with several movement disorders grouped together within the adverse effect of extra-pyramidal side effects.
- Tardive Dyskinesia: choreiform involuntary facial movements (tongue poking, open mouth, facial twitching), but can be of any part of the body
- Akathisia: inner feeling of restlessness
- Acute dystonia: sustained or brief involuntary muscle contractions; oculogyric crisis, laryngeal spasm, opisthotonus
- Parkinsonism: slowed gait, rigidity, cogweeling, impaired balance

Treatment:

• Cease/reduce antipsychotic medication, switch to one less likely to cause symptoms
• Anticholinergics (benzatropine) for acute treatment of EPSE whilst antipsychotic is being reduced/ceased.
• propanolol for tardive dyskinesia if symptoms are unbearable in the short term whilst medication is being ceased.

Question 3

Tardive dyskinesia - Assessment

Answer 3

History

• sx: facial twitching, tongue poking, time period over which the sx have developed.
• screen for other drug induced movement disorders - inner sense of restlessness, slowed gait, memory loss, muscle contraction (laryngeal spasm, oculogyric crisis)
• Other adverse effects of first generation antipsychotics: NMs, hyperprolactinaemia, cardiometabolic, antihistaminic, etc
• Ask about psychotic and other psychiatric symptoms to determine how well managed sx are. (psychotic, depressive, manic, suicide, etc)
• PMhx, previous adverse effects,
• medications: any recent changes, adherence
• substances: taking any additional substances, recent changes
• rest of psych history

Examination

• general appearance + obs (temperature)
• neurological examination: abnormal movements, rigidity, hyper vs hyporeflexia (diff serotonin syndrome vs NMS),

Investigations:

• bedside: vital signs, ECG (QTc changes)
• bloods, FBC, CK, UEC
• imaging: nil required at present in acute setting

Question 4

Tardive dyskinesia - Management

Answer 4

Management
Mainstay of treatment in EPSE is ceasing the current antipsychotic medication, or reducing dose, or switching to alternative medication.
- need to take into consideration risk assessment for relapse of symptoms: therefore determine appropriate location for treatment and management (ideally inpatient basis)

1) Cease haloperidol, is first generation anyway with increased risk for EPSE so would advise switching to second generation AP

2) consider acute management of symptoms:
Supportive
- regular monitoring, regular bloods
- fluids (particularly if raised CK, risk of AKI)

Pharmacological
- not for tardive dyskinesia but for other EPSE if present; can use anticholinergic medication (benzatropine), and if significant akathisia can utilise propanalol for symptomatic treatment.

Definitive

• cease haloperidol
• switch to second gen (risperidone, quetiapine, aripirazole), as have lower risk of causing
• would want to observe whilst ceasing/switching medications to ensure stability before discharge