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What is dystonias
spasms of the tongue, neck, and back
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What is akathisia
continuous restlessness, inability to sit still; suicide risk
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what is pseudoparkinsonism
muscle tremors, cogwheel rigidity, drooling, shuffling
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what is tardive dyskinesia
abnormal muscle movements such as lip smaking
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when is dystonias more common
with high potency APDs and respiradone
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types of dystonias
- torticollis- condition of limited neck motion
- opisthotonus- spasm of the body
- oculogyric crisis- restlessness, agitation, fixed stare
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How to treat EPS
- -decrease dose
- -anticholinergics (benzotropine-most used)
- -antihistaminics (benadryl)
- -dopamine agonists (amantadine)
- -benzodiazepines (lorazepam, clonazepam)
- -Beta-blockers (propanolol)
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Cause of tardive dyskinesia
- -high potency typical APDs
- -prolonged DA receptor blackade which leads to super sensitivity of DA receptors
- -increase DA activity with relative decrease cholinergic activity
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Cardinal features of neuroleptic malignant syndrome
- -fever > 38 C
- -autonomic dysfunction
- -altered level of consciousness
- -absolute rigidity (lead pipe, tensing muscle)
- -elevated CPK-muscle and elevated WBC
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Cause of hyperprolactinemia/sexual dysfunction
- -low potency conventional APDs (thioridizine, chlorpromazine)
- -Resperidone
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symptoms of hyperprolactinemia
- galactorrhea
- amenorrhea
- decrease estrogen- CVD, breast cancer
- sexual dysfunction
- anxiety, hostility
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how to treat hyperprolactinemia
- -decrease dose
- -switch agent
- -use DA agonists (bromocriptine, amantidine)
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Metabolic Syndrome
- >= 3 of the following
- -abdominal obesity
- -dyslipidemia
- -HTN= BP >=135/85
- -IFG >= 100mg/dL
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Drugs especially seen to prolong QT interval
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general treatment algorithm principles
- -thorough assessment
- -monotherapy
- -considerations
- -allow 2-4 wks for effect to accur
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What to do if pt sx do not decrease during first wks of therapy
augment w/2nd agent or switch to alt agent
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monitoring-typical response (1-3 days)
- -decreased agitation
- -hostility
- -aggression
- -normal sleep, eating
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monitoring-typical response (1-2 wks)
- -improved socialization
- -improved mood
- -improved self-care habits
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monitoring-typical response (3-6 wks)
- -improvement in thought disorder
- -decrease in + Sx (hallucinations, delusions)
- -more appropriate conversations
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monitoring- pre-treatment physical assessments
- BMI
- HR
- BP
- waist circumference
- signs of movement disorder
- -EPS
- -TD
- CBC
- WBC with differential for clozapine
- ECG (pts with cardiac history or on AP that may prolong the QT interval
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1st line agents
- olanzapine
- ziprasidone
- abilify
- quetiapine
- risperidone
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2nd line agents
typical APs
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adjunctive therapy agents
- used to treat the side effects from APDs
- -anticholinergics
- -propanolol
- -BZD
- -antidepressants
- -APs (IM)
- -zolpidem
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Step 1:
single SGA (try to avoid olanzapine bc of problems with weight gain)
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Step 2:
In 2 weeks if patient is not doing that well then switch to another SGA not used above
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Step 3:
if partial or no response to 2 treatments(two failed treatments) then try clozapine if pt agrees. if not, then try another agent.
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Step 4:
- 3 failed treatments:
- -clozapine + (SGA, CAP, ECT)
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Step 5:
single SGA not used above or CAP
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Step 6:
try anything; combination therapy
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treatment algorithm for co-existing agitation/excitement
PO/IM BZD or AP PRN
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Treatment algorithm- co existing insomnia
- BZD or zolpidem PRN
- non responder= trazadone
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treatment algorithm-co existing depression
SSRIs (nefazadone, venlafaxine, bupropion, mirtazapine)
- non responder= reevaluate
- non-respnder= go to next step in algorithm
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