Clinical teaching on Management of extra pyramidal symptoms - psychiatric nursing

This ppt discusses in brief about the extra pyramidal symptoms and its management

1. CLINICAL
TEACHING ON
MANAGEMENT
OF EPS
PRESENTED BY
MS. ALICE SYLVIYA S
LECTURER,
DEPT. OF PSYCHIATRIC NURSING,
CON, SRIPMS.

2. INTRODUCTION
■Extrapyramidal side effects (EPS), commonly referred as drug-
induced movement disorders are among the most common adverse
drug effects patients experience from anti psychotics.
■ It was first described in 1952 after chlorpromazine-induced
symptoms resembling Parkinson disease.
■ The symptoms of EPS are debilitating, interfering with social
functioning and communication, motor tasks, and activities of daily
living.
■This is often associated with poor quality of life and abandonment of
therapy, which may result in disease relapse and re-hospitalization,
particularly in schizophrenic patients stopping pharmacologic
therapy.

3. WHAT ARE THE TYPES OF
EPS?
“ADAPT-Right Now”
Acute Dystonia
Akathisia
Pseudo- Parkinsonism
Tardive dyskinesia
Rabbit syndrome
Neuroleptic Malignant Syndrome

4. ETIOLOGY
■First-generation antipsychotics like haloperidol and
phenothiazine neuroleptics, are the most common
medications associated with EPS.
PATHOPHYSIOLOGY
■The mechanism of EPS is thought to be due to the
antagonistic binding of dopaminergic D2 receptors within
the mesolimbic and mesocortical pathways of the brain.

5. ACUTE DYSTONIA

6. ACUTE DYSTONIA
■Sudden onset of involuntary muscle contractions that cause
abnormal postures, twisting or repetitive movements.
■Typically affects muscles in neck (torticollis), face, eyes
(oculogyric crisis), back (opisthotonus).
■It may occur from 3 hrs – 48 hrs of drug intake, mostly occurs within
5 days.

7. TREATMENT OF ACUTE
DYSTONIA:
 Emergency airway intervention.
 Discontinuation of drug and management of pain if
present.
 Switching to an atypical antipsychotic.
 Administration of an antimuscarinic(type of
anticholinergic) agent (benztropine, trihexyphenidyl) or
diphenhydramine may relieve dystonia within minutes.

8. AKATHISIA
■Akathisia is characterized by a subjective feeling of internal
restlessness and a compelling urge to move, leading to the objective
observation of repetitive movements comprising leg crossing,
swinging, or shifting from one foot to another.
■Inability to sit still
■Pacing, fidgeting
■Anxiety / Agitation
■The onset is usually within four to twelve weeks of starting the
medication.

9. TREATMENT OF AKATHISIA:
 Strategies similar to managing dystonia are employed,
including stopping or reducing the dosage of the offending
medication, switching to an atypical antipsychotic.
 Administering anti-muscarinic agents.
 Additional therapeutic strategies more specific to akathisia
include administration of a beta-blocker (most commonly
propranolol), amantadine, clonidine, benzodiazepines, mirtazapine,
mianserin (tetracyclic antidepressant), cyproheptadine, and
propoxyphene.

10. PSEUDO PARKINSONISM
■Drug-induced parkinsonism presents as tremor, rigidity, and
slowing of motor function in the truncal region and extremities.
■The classic appearance is an individual with masked faces,
stooped posture, and a slow shuffling gait.
■Gait imbalance and difficulty rising from a seated position
are often noted.
■Cogwheel rigidity
■Drooling of saliva
■Akinesia
■Pill rolling tremors

11. TREATMENT OF PSEUDO
PARKINSONISM
■Discontinuation or dose reduction of the causative medication
■Switching to an atypical antipsychotic
■Administration of medications used for Parkinson disease,
including amantadine, antimuscarinic agents, dopamine
agonists, and levodopa.

12. TARDIVE DYSKINESIA
■Involuntary choreoathetoid movements affecting
orofacial and tongue muscles, and less commonly the
truncal region and extremities.
 
■Appears after chronic drug intake.(More than 6 months – 3
years)
■Symptoms are typically not painful but they may impede
social interaction.

13. TREATMENT OF TARDIVE
DYSKINESIA
■Discontinuation or dose reduction of the causative medication.
■Switching to an atypical antipsychotic.
■Injection of botulinum toxin for facial dyskinesia,
benzodiazepine and amantadine.

17. RABBIT SYNDROME
■Rapid, involuntary, repetitive movements of the
mouth, resembling a rabbit chewing.
■Continuous and repetitive movement of the lips and
mouth, without involvement of the tongue.

18. TREATMENT OF RABBIT
SYNDROME
■Discontinuation or dose reduction of the causative medication.
■Switching to an atypical antipsychotic.
■Anti cholinergics
■Occupational therapy

20. NEUROLEPTIC MALIGNANT
SYNDROME
■Neuroleptic Malignant Syndrome (NMS) is a rare medical emergency and requires
immediate intervention.
1.Hyperthermia
2.Severe muscle rigidity: "lead pipe" rigidity.
3.Altered mental status: This can range from confusion and agitation to delirium or coma.
4.Autonomic dysfunction: Symptoms include:
–Tachycardia)
–Blood pressure fluctuations (hypertension or hypotension)
–Sweating, salivation
–Tachypnea)

21. TREATMENT OF NEUROLEPTIC
MALIGNANT SYNDROME
•Immediate Discontinuation of Antipsychotic Medications
•Hospitalization is often required, and patients may need to be transferred to an
intensive care unit (ICU).
•Cooling the patient with external cooling methods (cooling blankets, ice packs) and
hydration (intravenous fluids)
•Pharmacological Interventions:
•Dantrolene: A muscle relaxant that reduces muscle rigidity and hyperthermia by
inhibiting calcium release in muscles.
•Bromocriptine or Amantadine
•Benzodiazepines
•Electroconvulsive Therapy (ECT)

22. NURSING MANAGEMENT OF EPS
•Assessment:
•Regularly monitor for signs and symptoms of EPS, including
tremors, rigidity, and involuntary movements.
•Assess the severity of symptoms and their impact on the patient's
daily functioning.
•Medication Management:
•Ensure adherence to prescribed medications, including the use of
antiparkinsonian agents (e.g., benztropine, trihexyphenidyl) to
manage symptoms.

23. •Patient Education:
•Provide information on strategies to manage symptoms, such as
regular physical activity and relaxation techniques.
•Supportive Care:
•Offer assistance with activities of daily living if EPS symptoms
interfere with the patient’s ability to perform them independently.
•Encourage participation in physical therapy or exercises that can
help improve motor function and reduce rigidity.

24. •Psychosocial Support:
•Address the emotional and psychological impact of EPS, including
anxiety or depression that may result from the symptoms, Provide
counseling.
•Coordination of Care:
•Collaborate with the healthcare team, ensure regular follow-up
appointments to monitor the progression of EPS and adjust
treatment as needed.
•Documentation:
•Document all observations, patient reports, and interventions
related to EPS to provide a comprehensive record for ongoing
care and treatment evaluation.