Side Effects and Tardive Dyskinesia

Transcription

1 Chapter Three Side Effects and Tardive Dyskinesia Medication Effect Although medications can significantly impact people s lives in a positive manner, it may concurrently alter a number of unrelated biological processes. Whenever a medication is taken, a number of biochemical responses within the body occur. Generally, medications have two types of effects, both the desired therapeutic response and unintended possible side effects. Side effects vary widely and can range from being mild and transitory to those warranting immediate medical attention. Ideally, the goal for pharmacotherapy is to produce optimal therapeutic effects while minimizing side effects. Side Effects (See PMCU Part V and Part VI) The primary outcome of pharmacotherapy is to treat the target behaviors or psychiatric symptoms. In addition to a medication s intended therapeutic effect, all drugs have unintended side effects, which may be rare to common, mild to severe. More serious side effects are referred to as adverse effects. These tend to be more unpredictable, often taking the form of idiosyncratic reactions, allergic reactions or toxicity (Rankin, 2000). It is common that two individuals taking the same medication might have vastly different experiences. Consumers with developmental disabilities are likely to experience the same range of side effects as the general population; however, several factors may complicate side effect identification (Kern, 1999). A developmental disability may mimic or obscure certain side effects, such as changes in speech or gait. An individual consumer may be able to report a side effect when asked, but not understand that a given sensation is a side effect or understand that the care provider should be notified. Consumers with speech impairments or communication deficits will have difficulty reporting side effects; however, they may be reflected as changes in behavior (Zelenski, 2002). Side effect information can be obtained in written form from the pharmacy, from drug reference manuals, or on the Internet (e.g., MEDLINEplus Health Information; rxlist.com). It is important the information be obtained from a reputable source. Information that differentiates non-urgent side effects from side effects that require immediate medical attention will be most helpful to the treatment staff.

2 Categorization of Side Effects Extrapyramidal Side Effects Extrapyramidal side effects (EPSE) are common and often occur with the use of antipsychotic medication (e.g., haloperidol [Haldol]). These effects are typically not dangerous and may be treated by lowering the dose of medication, changing to a medication with a lower profile of EPSE, or administering an anticholinergic medication (e.g., benztropine [Cogentin]) in conjunction with the antipsychotic medication. Common extrapyramidal side effects are akathesia, dystonia, and druginduced Parkinsonism. Symptoms associated with akathesia include: (a) pacing, (b) inner restlessness, and (c) leg aches that are relieved by movement. Rankin (2000) reports akathesia accounts for approximately 50% of the extrapyramidal side effects reported and is often associated with high potency medications such as haloperidol (Haldol) or fluphenazine (Prolixin). Dystonia is an acute movement disorder characterized by involuntary movements leading to persistent muscle contractions. Typically, it manifests as sudden spasms of major muscle groups of the neck, back, or eyes. These spasms can cause abrupt torsion of the neck, inability to open the jaw, and oculogyric (eye rolling) effects. In some cases, dystonias may cause laryngealpharyngeal constriction which makes breathing difficult and requires immediate medical attention. Risk factors associated with antipsychotic induced dystonia include young age, male gender, and the administration of high potency antipsychotics (Rankin, 2000). Drug-induced Parkinsonism causes diminished movements (akinesia), restlessness (akathesia), cogwheel rigidity, bilateral fine tremors, and a "pill rolling" motion of the fingers. Parkinsonism symptoms account for approximately 40% of all extrapyramidal side effects and occur twice as often in females as males (Varcarolis, 1998). The onset of symptoms may occur within a few weeks or it may take several months to emerge. Tolerance to these symptoms does not develop; however, early intervention with anticholinergic medications may help minimize these effects (Weiden, 1996; Rankin, 2000). The standard protocol for treatment of antipsychotic-induced EPSE is to reduce the dose of the antipsychotic or change to a medication having less potential to cause similar side effects. If these approaches are ineffective, an anticholinergic medication should be prescribed. Treatment with anticholinergic medication (see Chapter Two) is recommended for at least a 3-month duration, an adequate time for a response. Gradual reduction over a period of time is suggested until the anticholinergic medication can be withdrawn. If extrapyramidal side effects re-emerge, the anticholinergic should also be restarted (Rankin, 2000). Tardive Dyskinesia Specific to antipsychotic medications, amoxapine (Ascendin, an antidepressant), and metoclopramide (Reglan), (Physician Desk Reference, 2003).

3 Tardive dyskinesia (TD) is a central nervous system disorder characterized by involuntary motor movements of the face, tongue, trunk, and limbs. Prolonged use of antipsychotic medication can result in tardive dyskinesia. Stahl (2000) reports that about 5% of individuals maintained on typical antipsychotic medications will develop tardive dyskinesia each year (i.e., 20% in 4 years). Neuroleptic Malignant Syndrome Neuroleptic malignant syndrome (NMS) is a potentially lethal disorder which can occur when dopamine antagonists are used (Keltner, 1998). These medications include the typical and atypical antipsychotics (see Chapter Two). Neuroleptic malignant syndrome is characterized by extreme muscle rigidity, elevated body temperature, mental changes, and an elevated Creatine Phosphokinase (CPK) level. Treatment requires the immediate withdrawal of antipsychotic medications. Supportive care includes rehydration and fever reduction. Bromocriptine (Parlodel) a dopamine agonist, and dantrolene (Dantrium), a muscle relaxant, are also used to treat and reduce the life-threatening symptoms of NMS. Polydipsia Another possible side effect to psychotropic medications is polydipsia (water intoxication). This is a relatively rare side effect, occurring in less than 6% of psychiatric patients. It is believed to be related to the antipsychotic medication effect on the antidiuretic hormone. It causes the continuous release of the antidiuretic hormone when the secretion should be inhibited. This results in the loss of sodium through urine and can reduce serum sodium levels to dangerously low levels (hyponatremia) while increasing the retention of free water. Behavioral changes as well as physiological effects may occur. Irritability, anxiety, and increased agitation are often present. Rapid weight gain, headache, nausea, vomiting, lethargy, along with abdominal and muscle cramping may also occur. If left untreated, cerebral edema and seizures may result. Treatment generally involves limiting fluid intake (Thompson, McFarland, Hirsch, Tucker & Bowers, 1986; Frisch & Frisch, 1998; Rankin, 2000). Assessing for Side Effects Biological side effects can manifest in any body system. These include: cardiovascular (e.g., dizziness, low blood pressure) endocrine/metabolic (e.g., weight gain, lethargy) reproductive/sexual (e.g., changes in menstrual cycle) hematologic/immunologic (e.g., decreases in white blood cell count) gastrointestinal (e.g., constipation, diarrhea) hepatic (e.g., liver toxicity) renal/genitourinary (e.g., incontinence, low sodium levels) neuromuscular (e.g., tremors, involuntary movements)

4 neurological (e.g., seizures, unsteady gait) respiratory (e.g., difficulty breathing) dermatologic (e.g., skin rash) sensory (e.g., vision changes) Behavioral side effects (central nervous system) include: agitation/restlessness sedation impaired memory hostility disinhibition aggression mania sleep disturbances withdrawal reactions (Kalachnik et al., 1998) Use of a standardized instrument provides a more objective and systemic assessment, and results in more reliable data for identifying side effects. Assessment Tools (See PMUC Part V and Part VI) A variety of assessment tools have been published to address both general side effects as well as specific side effects. The general scales can be used with a variety of medications; however, they may be too general and list many side effects that do not apply to the prescribed medication. The specific side effect scales address a narrower range of side effects such as tardive dyskinesia or akathesia. Kalachnik (1999) describes a number of general and specific side effect scales. General Scales include: ADRDS -- Adverse Drug Reaction Detection Scale (Corso et al., 1992) DOTES -- Dosage Record and Treatment Emergent Symptom Scale (National Institute of Mental Health, 1985) MOSES -- Monitoring of Side Effects Scale (Kalachnik, 1985) SAFTEE -- Systematic Assessment for Treatment Emergent Effects (Levine & Schooler, 1986) STESS -- Subjective Treatment Emergent Symptoms Scale (National Institute of Mental Health, 1985)

5 Side Effect Specific Scales for Tardive Dyskinesia AIMS -- Abnormal Involuntary Movement Scale (National Institute of Mental Health, 1985) DISCUS -- Dyskinesia Identification System Condensed User Scale (Sprague & Kalachnik, 1991) TDRS -- Tardive Dyskinesia Rating Scale (Simpson et al., 1979) TRIMS -- Texas Research Institute for Mental Sciences (Smith et al., 1983) Frequency of Assessments The frequency at which side effects should be assessed is somewhat variable. Although specific guidelines are provided in the Psychotropic Medication Use Checklist (Minnesota Department of Human Services, 2004) more frequent assessment may be advisable depending upon risk factors, treatment phase, and client response to psychotropic medications. Approach to Monitoring Side Effects Consumer and Care Provider Education Licensed service providers and interdisciplinary team members should be familiar with both the long and short-term side effects of psychotropic medications and how to assess for potential concerns. The consumer, interdisciplinary team, licensed service provider, and individual mental health practitioner should all participate in determining which standardized assessment instrument to use in evaluating side effects. The prescribing practitioner should be a valuable resource in providing information and educating the consumer and team. It is important that proper training on the use of the scale is obtained and the same scale be used consistently for side effect monitoring. Because some side effects associated with psychotropic medication use might be alarming but easily treated before severe side effects result, the early identification and intervention are important. Team members and service providers should be cautioned about not abruptly withdrawing psychotropic medication. Alcohol and over-the-counter antihistamines and cold remedies that can cause sedation should be avoided due to the potential for excessive sedation. There is an increased risk of photosensitivity with some psychotropic medications (e.g., chlorpromazine [Thorazine]; nortriptyline [Pamelor]). Reduced sun exposure or the use of sun block is recommended. Specific contraindications and instructions should be provided by the prescribing practitioner at the time the medication is initiated. Additional sources of information include: (a) a pharmacist, (b) resource books (e.g., the Physician Desk Reference, The Nursing Drug Handbook, Quick

6 Reference for Psychopharmacology), and (c) the Internet (e.g., MEDLINEplus Health Information; rxlist.com). Frequently Asked Questions What is tardive dyskinesia? Tardive dyskinesia is a central nervous system disorder characterized by involuntary motor movements of the face, tongue, trunk, and limbs. Prolonged use of antipsychotic medications (as well as amoxapine, metoclopramide) can produce tardive dyskinesia. If a consumer has been stable on an antipsychotic medication for over a year with no tardive dyskinesia, does monitoring need to continue? Yes, monitoring should continue using a standardized assessment tool at regular intervals. Tardive dyskinesia is associated with the long-term use of antipsychotic medications, and appears more likely with the use of the older antipsychotics (e.g., chlorpromazine [Thorazine], thioridazine [mellaril). Does tardive dyskinesia monitoring need to be done for all psychotropic medications? No, tardive dyskinesia is a central nervous system disorder associated with specific medications, including antipsychotics, amoxipine (Ascendin), and metoclopramide (Reglan). How do I know if a behavior is a medication side effect or a stereotypical behavior in someone who is nonverbal? A baseline assessment of body systems that may be affected should be completed prior to initiating a psychotropic medication to evaluate for pre-existing rates of unusual movements or behaviors. When should assessments for side effects be completed? Although specific guidelines are established in the Psychotropic Medication Use Checklist, the frequency should be based more on individual consumer s needs. If a consumer is in a higher risk group, undergoing multiple lifestyle changes, or has a history of experiencing side effects, it may be advisable to conduct side effect assessments more frequently. How do you assess for side effects if the consumer cannot communicate verbally? Monitoring for medication side effects is more difficult for consumers with communication challenges. Using a standardized instrument should provide an objective assessment. Side effects may also be demonstrated as challenging behaviors.

7 References Corso, D. M., Pucino, F., DeLeo, J. M., Calis, K. A. & Gallelli, J. F. (1992). Developmental of a questionnaire for detection potential adverse drug reactions. Annals of pharmacotherapy, 26, Frisch, N. & Frisch, L. (1998). Psychiatric mental health nursing. Albany, NY: Delmar Publishers. Kalachnik, J. E. (1985). Medication monitoring procedures: Thou shall, here s how. In K. D. Gadow & A. G. Poling (Eds.), Pharmacotherapy and mental retardation (pp ). Boston: College Hill. Kalachnik, J. E., Leventhal, B. L., James, D. H., Sovner, R., Kastner, T. A., Walsh, K., Weisblatt, S. A., & Klitzke, M. G. (1998). Guidelines for the use of psychotropic medications. In S. Reiss & G. Aman (Eds.), Psychotropic medications and developmental disabilities: The international consensus handbook. (pp ) Columbus: Ohio State University, Nisonger Center. Kalachnik, J. E. (1999). Monitoring psychotropic medication. In N. A Wieseler & R. H. Hanson (Eds.), Challenging behaviors of persons with mental health disorders and severe developmental disabilities. (pp ), Washington, D.C.: American Association on Mental Retardation. Keltner, N., Folks, D., Palmer, C., & Powers, R., (1998). Psychobiological foundations of psychiatric care. St. Louis, MO: Mosby. Kern, C. A. (1999). Psychopharmacotherapy for people with profound and severe mental retardation and mental disorders. (pp ). In N. A Wieseler & R. H. Hanson (Eds.), Challenging behaviors of persons with mental health disorders and severe developmental disabilities. (pp ). Washington, D.C.: American Association on Mental Retardation. Levine, J., & Schooler N. R. (1986). SAFTEE: A technique for the systematic assessment of side effects in clinical trials. Pharmacology bulletin, 22, Minnesota Department of Human Services (2003). Psychotropic Medication Use Checklist. St. Paul: Author. National Institute of Mental Health. (1985). DOTES (Dosage record and treatment emergent symptom scale). Psychopharmacology Bulletin, 22, Physician Desk Reference (2003). Montvale, NJ: Medical Economics. Rankin, E. A. (2000). Quick reference for psychopharmacotherapy. Albany, NY: Delmar. Simpson, G. M., Lee, J. H., Zoubok, B., & Gardos, G. (1979). A rating scale for tardive dyskinesia. Psychopharmacotherapy, 64, Smith, R. C., Allen, R., Gordon, J., & Wolff, J. (1983). A rating scale for tardive dyskinesia and parkinsonian symptoms. Psychopharmacology Bulletin, 19, Sprague, R. L. & Kalachnik, J. E. (1991). Reliability, validity, and a total score cut off for dyskinesia identification system: Condensed user rating scale (DISCUS) with mentally ill and mentally retarded populations. Psychopharmacology Bulletin, 27,

8 Stahl, S. M. (2000). Essential Psychopharmacology: Neuroscientific basis and practical applications. New York, NY: Cambridge University Press. Thompson,J. M., McFarland, G. K., Hirsch, J. E., Tucker, S. M., & Bowers, A. C., (1986). Clinical nursing. St. Louis, MO: C. V. Mosby Company. Varcarolis, E. (1998). Foundations of psychiatric mental health nursing (3rd ed.). Philadelphia: W. B. Saunders. Zelenski, S. G. (2002). Evaluation for and use of psychopharmacologic treatment in crisis intervention for people with mental retardation and mental illness. In R. H. Hanson, N. A. Wieseler & K. C. Lakin (Eds.), Crisis prevention and response in the community. (pp ). Washington, D.C.: American Association on Mental Retardation.