A 75-year-old female presents to the emergency room with a broken hip and is given an analgesic for pain relief. Her medications include a monoamine oxidase inhibitor, phenelzine, which she has taken for many years. Shortly after receiving the analgesic she becomes nauseated, diaphoretic, and her blood pressure increases to 190/110.
What analgesic was responsible for this reaction?
Correct Answer A:
Meperidine (Demerol) is contraindicated in patients taking monoamine oxidase inhibitors. It can result in a serotonin syndrome that can include severe hypertensive crisis, occipital headache, stiff neck, sweating, nausea, restlessness, muscle twitches, seizures, and high fever. Morphine and codeine in high doses or in a patient on other potentiating medications could lead to this syndrome as well, but meperidine is the most likely culprit.
A patient who has been placed on an antipsychotic drug for schizophrenia develops symptoms of tardive dyskinesia. He has lip smacking and tongue protrusion and muscular movements of his face.
What is the treatment for this side effect?
Correct Answer D:
The side effects of antipsychotic medications are as follows:
Parkinsonism: involves tremor, increased muscle tone, bradykinesia or akinesia, drooling, postural instability, loss of spontaneity, micrographia, seborrhea.
Treatment of this side effect: Lower dose or change to low-potency or atypical agent. Add anticholinergic agent.
Akathisia: motor restlessness accompanied by a feeling of inner restlessness (sometimes described as anxiety), an urge to move, and an inability to sit still, patients may pace or continuously move their feet and legs. Treatment of this side effect: Lower dose. Add benzodiazepine or beta blocker.
Dystonia: sustained contraction of muscles, twisting postures and may be visible only when the patient is moving. Neck and arm muscles are most commonly affected. Treatment of this side effect: Add anticholinergic agent or antihistamine. Lower dose or change to low-potency or atypical agent.
Tardive dyskinesia: hyperkinesia, involuntary body movements most often of the muscles of the face, mouth, and tongue. Treatment of this side effect: Lower dose or discontinue agent or change to low-potency or atypical agent.
Which of the following is the most accurate description of tardive dyskinesia?
Correct Answer E:
Tardive dyskinesias (TDs) are involuntary movements of the tongue, lips, face, trunk, and extremities that occur in patients treated with long-term dopaminergic antagonist medications. People with schizophrenia and other neuropsychiatric disorders are especially vulnerable to developing TDs after exposure to conventional neuroleptics, anticholinergics, toxins, substances of abuse, and other agents. TDs are most common in patients with schizophrenia, schizoaffective disorder, or bipolar disorder who have been treated with antipsychotic medication for long periods, but TDs occasionally occur in other patients as well.
Tardive dyskinesia may persist after withdrawal of the drug for months, years or even permanently.
TDs may be differentiated from acute movement disorders that commonly occur in the same patient groups. The acute movement disorders that occur as manifestations of effects of neuroleptics and other dopamine antagonists include akathisia, acute dystonia, and other hyperkinetic dyskinesias. Acute effects of dopamine antagonists also include Parkinsonian syndromes manifested by bradykinesia, rigidity, and pill rolling tremor. The acute movement disorders resulting from exposure to dopamine antagonists are commonly termed extrapyramidal syndromes (EPS).
You diagnosed tardive dyskinesia in a 72-year-old white female with schizophrenia. She lives in a nursing home and has been treated with haloperidol (Haldol), 1 mg twice a day, for 5 years. She also has a hiatal hernia.
Which one of the following statements is true regarding this patient?
Correct Answer B:
Symptom remission is more likely to occur after neuroleptic withdrawal in young patients than in the elderly (choice A). Tardive dyskinesia is initially exacerbated by a reduction in neuroleptic dosage, and dyskinesias decrease following an increase in the dosage.
Metoclopramide (choice C) has been shown to cause tardive dyskinesia with long-term treatment, and therefore would not be the best drug for the patient’s hiatal hernia.
There is no convincing evidence that any of the traditional antipsychotic drugs (choice D) is less likely to produce tardive dyskinesia than any other, but the newer atypical agents such as clozapine, risperidone, and olanzapine offer some hope for a reduced incidence.
You evaluate an 80 year old white male who is a heavily medicated chronic schizophrenic. You note constant, involuntary chewing motions and repetitive movements of his legs.
Which one of the following is the most likely diagnosis?
The patient has classic signs of tardive dyskinesia. Repetitive movement of the mouth and legs is caused by antipsychotic agents such as phenothiazides and haloperidol. Neuroleptic malignant syndrome consists of fever, autonomic dysfunction, and movement disorder. Acute dystonia involves twisting of the neck, trunk, and limbs into uncomfortable positions. Huntington’s disease causes choreic movements, which are flowing, not repetitive. Oculogyric crisis involves the eyes.
Click to expand